Medical decision making for E/M services

Part 3 of 3

Along with history and physical examination, the complexity of medical decision making
is the third key component for documentation and coding of evaluation and management
(E/M) services. Current Procedural Terminology (CPT-4®) identifies four types
of complexity in medical decision making: high, moderate, low and straightforward.
Each type is defined by meeting or exceeding the minimum requirements for two of three
elements (see Table 1):

number of diagnoses or management options,

amount and/or complexity of data to be reviewed and

risk of complications, morbidity and/or mortality.

Art by Thinkstock.

In this month's column, we'll focus on the third element: the risk of complications,
morbidity and/or mortality, which is a highly subjective, complex determination. Risk
is classified as minimal, low, moderate or high. Classification is based on the highest
level of risk on the date of service in any one of the following three categories:

Presenting problems—the expected risk between the current and next encounters
associated with the number and severity of current, active diagnoses and conditions
(e.g., cellulitis, ruptured appendix, syncope, hypovolemic shock).

Management/treatment options—risks associated with a therapeutic procedure
or other treatment on the date of service (e.g. chemotherapy, coronary artery bypass
graft, patient-controlled analgesia pump, radiation therapy).

The only specific guidance in assigning level of risk is the so-called “Table
of Risk” (see Table 2) found in the “Documentation Guidelines for Evaluation and Management (E/M)
Services” from the Centers for Medicare and Medicaid Services' Medical Learning
Network. This table provides examples to assist physicians in the assignment of risk
but requires clinical judgment and interpretation for application. The Marshfield
scoring system does not provide additional assistance with risk assignment, simply
referring to the Table of Risk.

In summary, become familiar with the Table of Risk to guide your risk assessment.
On each date of service, document the current diagnoses and conditions being actively
managed, diagnostic procedures, and therapeutic procedures and other management/treatment
provided to indicate the associated risks. Remember that the highest level of risk
associated with any one of these three categories determines risk for the encounter
on that date of service.

Richard Pinson, MD, FACP, is a certified coding specialist and cofounder of HCQ Consulting in Houston. This content is adapted with permission from HCQ Consulting.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.